Physical Assessment of the Integumentary System

Integument means covering. Integument means covering. The skin and its accessory organs, hair, nails and glands comprise the integumentary system of the body. The skin and its accessory organs, hair, nails and glands comprise the integumentary system of the body. The skin is composed of several different tissue types and is considered an organ. The skin is composed of several different tissue types and is considered an organ.

Functions of the Integument Protection Protection Physical Barrier Physical Barrier Perception Perception Temperature Regulation Temperature Regulation Identification Identification Communication Communication

Functions of the Integument continued Wound Repair Wound Repair Absorption Absorption Excretion Excretion Vitamin D Production Vitamin D Production

The Three Layers of the Integument Epidermis - the outermost layer of the skin, made of stratified squamous epithelium. Epidermis - the outermost layer of the skin, made of stratified squamous epithelium. Dermis - the inner layer of the skin, made of dense fibrous connective tissue. Dermis - the inner layer of the skin, made of dense fibrous connective tissue. Subcutaneous tissue - thick, fat-containing tissue. Below the skin; the tissues between the dermis and the muscles. Subcutaneous tissue - thick, fat-containing tissue. Below the skin; the tissues between the dermis and the muscles.

Epidermal Appendages Hair is threads of keratin Hair is threads of keratin Sebaceous glands secrete the oil, sebum Sebaceous glands secrete the oil, sebum Sweat glands Sweat glands –Eccrine glands secrete sweat –Apocrine glands secrete thicker, milky secretion as in anogenital, nipples, and illae areas Nails are hardened keratin Nails are hardened keratin

Receptors in the skin The sensory receptors in the dermis are for cutaneous sensations which include: touch, pressure, heat, cold, and pain. The sensory receptors in the dermis are for cutaneous sensations which include: touch, pressure, heat, cold, and pain. The purpose of sensory receptors is to provide the CNS with information about the external environment and its effect on the skin. The purpose of sensory receptors is to provide the CNS with information about the external environment and its effect on the skin.

Interview Chief Complaint Chief Complaint –Recent Changes –Pruritus (itching) – Dryness (xerosis) – Rashes (identify primary site, migration, pattern and evolution –Lesions –Ecchymoses (bruising) –Masses or lumps Symptom analysis Symptom analysis –Pages , Jarvis

Interview (cont.) Past Health History Past Health History –Example: Immunologic, Endocrine, Collagen, Vascular, Renal, Hepatic Immunologic, Endocrine, Collagen, Vascular, Renal, Hepatic –Previous exposure to insects, infectious disease –Previous trauma & surgical intervention –History of past allergic reactions

Interview (cont.) Medications Medications –Sensitivities –Photosensitizing drugs –Ask about self treatment with herbal remedies Allergies Allergies –Medications & Foods

Interview (cont.) Family Health History Family Health History –Helps determine genetic predisposition to skin disorders Psychosocial History Psychosocial History –Particularly important in long-term & chronic processes. –Determine & correct any misconceptions about skin problems.

Interview (cont.) Diet Diet –Excessive dryness may indicate Vitamin A deficiency. Occupation & Travel Occupation & Travel –What have they been exposed to. Habits Habits –Frequency of hygiene practices. –Exercise & Sleep Patterns Affects circulation, nourishment, & repair of the skin. Affects circulation, nourishment, & repair of the skin. –Is there prolonged exposure to sun, unusual cold, or other skin damaging conditions.

Dermatologic Assessment History Chief complaint Chief complaint Definition of problem (onset, location) Definition of problem (onset, location) Duration Duration Accompanying manifestations Accompanying manifestations Evolution of lesion or eruption Evolution of lesion or eruption Aggravating & relieving factors Aggravating & relieving factors

Dermatologic Assessment History Medical intervention Medical intervention Self-treatment Self-treatment Compliance & treatment factors Compliance & treatment factors

Preparation for the Physical Examination Strong direct lighting, natural sunlight is best Strong direct lighting, natural sunlight is best Small centimeter ruler Small centimeter ruler Penlight Penlight Gloves Gloves Wood’s light (ultraviolet light) may be needed for special procedures Wood’s light (ultraviolet light) may be needed for special procedures

Inspection Color, Page 249 Jarvis Color, Page 249 Jarvis –Pallor –Cyanosis –Erythema –Jaundice –Document presence of tattoos General pigmentation General pigmentation Areas of hypopigmentation or hyperpigmentation Areas of hypopigmentation or hyperpigmentation Abnormal color changes Abnormal color changes

Hair and scalp Inspection Inspect distribution & quality Inspect distribution & quality Texture Texture Inspect the Scalp: Inspect the Scalp: –Lesions –Excoriations –Lumps –Bruises –Lice

Nails Color, Shape & Contour Color, Shape & Contour Texture Texture Integrity Integrity Thickness Thickness Capillary refill Capillary refill

Palpation Temperature Temperature –Assess with dorsum of hand –Warmth reflects circulation –Compare sides Moisture Moisture –Refers to the skin’s hydration level in terms of both wetness & oiliness –Diaphoresis, dehydration Texture Texture –Should feel smooth, soft, & resilient

Palpation continued Tenderness Tenderness Thickness Thickness –Callus –Atrophic Edema Edema –Not a “normal finding” –Common in some disorders Cardiovascular Cardiovascular Renal failure Renal failure Cirrhosis Cirrhosis

Edema grading –May be pitting –1+ Barely Visible –2+ Indentation < 5mm –3+ Indentation of 5 to 10mm –4+ Indentation of 10mm or >

Palpation continued Turgor Turgor –Reflection of skin’s elasticity & hydration –Turgor is decreased (less elasticity) as the skin “tents” and stands by itself Hygiene, odor Hygiene, odor Vascularity or bruising Vascularity or bruising

Lesion Types Types of Lesions Types of Lesions –Primary - those developing from previously unaltered skin –Secondary – those which develop over time because of a factor such as scratching or infection

If any Lesions present, note the: Color Color Shape and configuration Shape and configuration Size Size Elevation Elevation Excudate Excudate Location and distribution Location and distribution Table 12-3 to 12-11, pages , Jarvis Table 12-3 to 12-11, pages , Jarvis

Self-Care Behaviors Teach skin self-examination, using the ABCDE rule A—asymmetryB—borderC—colorD—diameter E—elevation and enlargement

Developmental Considerations Infants Infants –Lanugo (fine downy hair) from 3 months gestation to a few months after birth –Thin, smooth, highly permeable and elastic skin –Increased sebum through the first few weeks of life –Temperature regulation inefficient

Developmental Considerations Aging Adults Aging Adults –Skin loses elasticity and underlying fat reserves –Vascularity diminishes –Decreased response of sweat glands –Lifetime of environmental trauma –Wound healing decreased –Melanocytes decreases melanin production –Loss of self-esteem